Provider Demographics
NPI:1578278974
Name:BACON, KARSON KANANI
Entity Type:Individual
Prefix:
First Name:KARSON
Middle Name:KANANI
Last Name:BACON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5869 WILSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-5696
Mailing Address - Country:US
Mailing Address - Phone:909-434-6695
Mailing Address - Fax:
Practice Address - Street 1:219 42ND ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97478-5937
Practice Address - Country:US
Practice Address - Phone:541-224-6897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician